Intended for healthcare professionals

Letters NICE guidelines on acute heart failure

Concerns about latest NICE guidelines on acute heart failure

BMJ 2014; 349 doi: (Published 12 November 2014) Cite this as: BMJ 2014;349:g6707
  1. D K Satchithananda, consultant cardiologist1,
  2. A Patwala, consultant cardiologist1,
  3. D Barker, consultant cardiologist1,
  4. G Dwivedi, associate professor2,
  5. M Mamas, consultant cardiologist3
  1. 1Royal Stoke University Hospital, Stoke on Trent, UK
  2. 2Ottawa Heart Institute, Ottawa, Canada
  3. 3Manchester Royal Infirmary, Manchester, UK
  1. Dargoi.satchi{at}

We have several comments on the summary of the National Institute for Health and Care Excellence (NICE) acute heart failure guideline.1

The guideline fails to define acute heart failure and to differentiate it from hospital admission for heart failure. The two conditions are not synonymous. Acute heart failure is the final clinical presentation of differing haemodynamic “phenotypes,” with less than half of presentations due to pulmonary oedema or cardiogenic shock.2 3 Other guidelines suggest that the time between the onset of symptoms of acute deterioration and hospital admission is days to weeks.3

We are not aware of any evidence that starting β adrenergic blockers in hospital reduces mortality or readmissions. Benefits accrued in the US of downstream β blocker titration may be subsumed with implementation of NICE quality standards for chronic heart failure.4 Appropriate early initiation and titration of β blockers in the community should not be penalised if the above recommendation becomes a quality standard.

We are also unaware of any evidence of improved patient outcomes, quality of care, or cost effectiveness to support prolonging the hospital stay for “typically” another two days after starting β blockers. Inappropriate prolongation of hospital stay is counterintuitive to initiatives aimed at reducing bed usage for heart failure and other ambulatory sensitive conditions.5 It also increases time spent away from home, without demonstrated benefit, in a patient group identified as vulnerable to readmission or death.

The traditional hospital centred model for acute heart failure is increasingly unaffordable. Alternative methods of care delivery based on individual presenting acute heart failure phenotype have been suggested.5 The successful delivery of out of hospital solutions may be more cost effective than the research priorities suggested in the guideline.


Cite this as: BMJ 2014;349:g6707



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